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What are the various types of headaches according to the International Headache Society Classification System?

migraine, tension-type, cluster and other trigeminal autonomic cephalagias, other primary headaches and secondary headaches

What are the two types of migraine?

migraine with aura (visual disturbance) and migraine without aura

What causes the aura in a migraine?

decreased cerebral blood flow in occipital region; moves across the cerebral cortex; symptoms may be caused by neuronal dysfunction

What system regulates the pain associated with migraine without aura?

trigeminovascular system

What are premonitory symptoms?

signs that clue a patient that they are going to experience a migraine/headache in the days to come

What are some premonitory symptoms?

neurologic (sensitive to the light), psychological (anxiety), constitutional (stiff neck and yawning), and autonomic (diarrhea and constipation)

What are acute symptoms of migraine?

throbbing pain, unilateral, N/V in 30% and sensitivity to light

How long will auras typically last?

<60 minutes

What are diagnostic criteria for headache without aura?

At least five attacks, with each lasting 4 to 72 hours; HA has at least 2 of the following characteristics: unilateral location, pulsating quality and moderate to severe intensity; and during HA at least one of the following: N/V/both, photophobia/phonophobia, or not attributed to another disorder

What are diagnostic criteria for headache with aura?

At least two attacks and no attributable to another disorder, typical aura and at least one of the following: at least 1 symptom that develops gradually over a minimum of 5 minutes or different symptoms that occur in succession or both, each symptom lasts at least 5 minutes, but not more than 60, and HA that meets criteria for migraine w/o aura begins during the aura or follows aura within 60 minutes

What are the goals of therapy for acute treatment?

treat rapidly, restore function, minimize rescue meds, optimize self-care, cost-effective and avoid adverse effects

What are goals of therapy for chronic treatment?

reduce frequency, severity and disability, etc

What are some nonpharmacological treatments for HA?

ice, dark room or quiet environment / preventative measures like avoid triggers, keep a headache diary and good sleep/eating habits

What are some common triggers of HA?

alcohol, caffeine, chocolate, tyramine-foods, high altitude, loud noises, fatigue, stress, strenuous activity and even foods high in nitrates/chinese food

What are first-line treatments for mild to moderate acute migraine?

simple analgesic, acetaminophen, aspirin, caffeine, NSAIDs, ibuprofen, naproxen

If simple analgesics fail, what is next for mild to moderate migraine?

combination analgesics like Midrin, acetaminophen, or aspirin/butalbital/caffeine

What is third line treatment for mild to moderate migraine?

Triptans

What is the final option for treatment of mild to moderate migraine?

opioid combination analgesics, butorphanol nasal spray

What is first line treatment for severe migraine?

dihydroergotamine or ergotamine tartrate or triptans

What is second line treatment for severe migraine?

opioid combination analgesics, butorphanol nasal spray as well

What can be prescribed for nausea associated with a migraine attack?

Metoclopramide or ketorolac

How long should ketorolac be used for nausea in migraine?

5 days

What are some common AE for NSAIDs?

GI side effects (N/V/D and dyspepsia) so take with food / CNS effects (somnolence and dizziness) / watch for use in elderly, history of peptic ulcer disease and renal disease

What are some examples of ergotamine tartrate?

Cafergot, Ercaf and Migergot

What are some examples of dihydroergotamine?

DHE 45 and Migranal

What are ergot alkaloids and derivatives used for?

Moderate to severe migraine

What classification of drug are the triptans?

non-selective 5-HT1 agonists (also alpha adrenergic, beta adrengergic and dopaminergic)

What additional ingredient will ergotamine tartrates contain to increase analgesic effect?

Caffeine

What are some side effects of ergotamine/derivatives use?

N/V, weakness, fatigue, muscle pain, severe peripheral ischemia (ergotism), and rebound headache

What class of drugs should be avoided with the ergotamine/derivatives?

triptans (allow at least 24 hours to pass before taking one)

What groups are contraindicated for use of ergotamine/derivatives?

renal failure, liver failure, coronary, cerebral, peripheral vascular disease, hypertension and pregnancy

What is the only first-generation triptan?

sumatriptan

What are the second generation triptans?

zolmitriptan, naratriptan, rizatriptan, almotriptan, frovatriptan, and eletriptan

What are triptans indicated for?

first line treatment for moderate to severe migraine attacks

What is the triptan MOA?

5-HT1B and 5-HT1D agonist that leads to vasoconstriction / also does peripheral neuronal inhibition and inhibition of transmission of trigeminocervical complex

What should be noted about sumatriptan's duration of action?

has a short duration of action

What is common with sumatriptan use?

recurring headache

What are some benefits of the second-generation triptans?

longer half-lives, higher bioavailability and 2-hour effectiveness

What classes of drugs should not be used with triptans?

SSRI/SNRIs (monitor for serotonin syndrome), MAOIs, TCAs, ergot derivatives

What are some common side effects of triptans?

parasthesias, fatigue, dizziness, flushing, somnolence, and 'chest symptoms'

What groups are contraindicated for use with triptans?

ischemic heart disease, uncontrolled hypertension, cerebrovascular disease, hemiplegic/basilar migraine

What should be noted about sumatriptan in its injection formulation?

you can repeat after 1 hour prn and it has a bioavailability of 97%

Which triptan has the highest bioavailability?

Injection sumatriptan

What should be noted about naratriptan?

you can repeat its dosing after 4 hours prn

What can happen with overuse of medications for acute migraine?

Medication-overuse headaches

How long should therapy for acute migraine last?

2-3 days

When should preventative therapy be considered with regard to acute migraine?

pain does not subside with acute therapy, frequency of attacks is >2/week, patient has a CI to the acute therapy or headache attacks are predictable

What are options for preventative therapy of migraines?

propanolol, timolol, valproate, topiramate and others

What is first line for migraine prophylaxis where headache recurs in a predictable manner?

NSAID at the time of vulnerability

What is first line for migraine prophylaxis where you have healthy or comorbid hypertension, angina or anxiety?

beta adrenergic antagonist or verapamil

What is first line for migraine prophylaxis where you have comorbid depression or isomnia?

TCAs

What is first line for migraine prophylaxis where you have comorbid seizure disorder or manic-depressive illness?

Anticonvulsant followed by beta adrenergic antagonist or verapamil

What is an option for treatment of migraine that doesn't respond to other agents?

Methysergide

What is the efficacy of the beta blockers in reducing migraine?

55-80%

What patients should use caution with beta blockers?

congestive heart failure, peripheral vascular disease, asthma, diabetes, AV conduction disturbances and depression

What are some side effects of beta blockers?

hypotension, tired/dizziness and asthma exacerbation

What antidepressants can help with migraine?

TCAs (nortriptyline or protriptyline) / SSRI or SNRI (fluoxetine) and MAOIs (phenelzine)

What is the MOA for the anticonvulsants in helping with migraine?

enhance GABA-mediated inhibition, modulate excitatory NT glutamate, inhibition of Na and Ca ion channels

What are some anticonvulsants that help with migraine?

Valproate or divalproex, topiramate, and gabapentin

What are the first side effects to occur with anticonvulsant use?

N/V/D

What calcium channel blocker is the most widely used for migraine?

verapamil

What is a major side effect of calcium channel blockers like verapamil?

constipation and AV block

What is the appropriate trial for preventative therapy of migraine?

2-3 months (initiated low and go slow)

What should be the basis for choosing a regimen for migraine?

comorbidities and side effects

How long should continuation of medication be after frequency of attacks have diminished?

3-6 months

What is the most common primary headache disorder?

tension headaches

How long should tension headache last for it to be considered chronic?

180 days of the year

What does tension headache follow?

follows activation of supraspinal pain perception - no aura, but good for mild to moderate pain - typically triggered by stress

What are the most severe primary headache disorders?

Cluster headaches

When do cluster headaches tend to occur?

in the evening

How is pain described in a cluster headache?

unilateral, excruciating, penetrating, series lasting weeks to months and remission can be for years

What is the pathophysiology of cluster headaches?

hypothalamic dysfunction resulting in alterations in circadian rhythms and activated ipsilateral hypothalamic gray area

What are some acute treatment options for cluster headaches?

oxygen, ergotamine derivatives (take 3-7 days to break the cycle), triptans (SC sumatriptan most effective)

What are some preventative treatments for cluster headaches?

Verapamil (benefits after 1 week), lithium (with or without verapamil) and Ergotamine (with or without verapamil and lithium)

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